Report slams state institution for neglect, abuse, weak oversight

Story by

Ryan Gabrielson

California’s largest institution for the developmentally disabled risks losing millions of dollars in federal funding because of poor medical care and widespread failures to prevent abuse and thoroughly investigate when patients are harmed, state officials said in a confidential report.

The Department of Public Health inspection report presented a damning indictment of the Sonoma Developmental Center, which houses more than 500 people with cerebral palsy and other intellectual disabilities. Normally such reports are kept from the public, but California Watch obtained a copy of the 495-page document this week.

"Individuals have been abused, neglected, and otherwise mistreated and the facility has not taken steps to protect individuals and prevent reoccurrence," the report said. "Individuals were subjected to the use of drugs or restraints without justification. Individual freedoms have been denied or restricted without justification."

According to the report, the board-and-care institution must immediately upgrade patient care and abuse investigations to keep its federal certification. Without federal approval, the Sonoma center would lose reimbursement from the Medicare and Medicaid programs – crippling its budget and placing an even greater burden on the state.

For the Sonoma center, the penalty would cut off reimbursements that cover about half of its $160 million annual budget. Finance records show that the Medi-Cal program pays more than $6 million a month for patient care at the Sonoma center.

State regulators repeatedly faulted the in-house police force, the Office of Protective Services, for inadequate investigations.

“It leads one to believe that, in certain circumstances, it’s a lawless environment,” state Sen. Mark Leno, D-San Francisco, said of the inspection report.

In a series of stories this year, California Watch has reported that detectives and patrol officers at the institutions routinely fail to conduct basic police work, even when patients die under mysterious circumstances. In case after case, detectives and officers have delayed interviews with witnesses or suspects – if they have conducted interviews at all.

The force has also waited too long to collect evidence or secure crime scenes and has been accused of going easy on co-workers who care for the disabled.

The state Department of Developmental Services operates five centers that house nearly 1,700 patients with cerebral palsy and other intellectual disabilities in Sonoma, Tulare, Los Angeles, Orange and Riverside counties. California is budgeted to spend about $314,000 this year per developmental center patient.

Terri Delgadillo, director of the Department of Developmental Services, said the department "recognizes the action necessary to ensure the health and safety of residents at the Sonoma Developmental Center."

"Several key changes have already been made but more must be done," Delgadillo said in a statement. "Both the executive director and the clinical director have been replaced. Several other employees have been terminated or disciplined and investigations continue which could result in additional actions.”

The report includes the Sonoma center’s plans to correct its violations, which include hiring additional caregivers and retraining employees.